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Although preoperative antibiotics are used routinely in ankle fracture surgery, there is considerable variability in postoperative antibiotic dosing regimens amongst surgeons. The aim of this study is to compare the rate of surgical site infection (SSI) in patients receiving one dose of preoperative antibiotics to patients who received more than one dose of antibiotics. A single-center Level I Trauma Center retrospective review of patients with isolated closed ankle fractures who underwent open reduction internal fixation over a 10-year period was performed. Demographics data and risk factors were obtained from the electronic medical record. SSI was detected using a text-mining algorithm on all postoperative clinic notes. Factors associated with the development of SSI or increased antibiotic dosing were evaluated. Eight-hundred and twenty-six patients were included in the analysis. There was no correlation between infection rate and any of the potential risk factors evaluated. Two-hundred and ninety-two patients received only one dose of antibiotics preoperatively and 534 patients received more than one antibiotic dose. The rate of SSI was not significantly different between the single-dose cohort (5.8 %) and the multi-dose cohort (3.9 %) (p=0.215). Routine use of postoperative antibiotics in open reduction internal fixation of closed ankle fractures did not decrease the rate of SSI, regardless of associated comorbidities. LEVEL OF EVIDENCE: : Level III (therapeutic retrospective cohort study)., Competing Interests: Declaration of competing interest None reported., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: This study aimed to compare 30-day post-operative mortality, and revision for aseptic femoral component loosening and all-causes following hip hemiarthroplasty performed with or without pressurisation of the bone cement in neck of femur fracture patients., Methods: Design: Retrospective cohort study., Setting: Level I trauma center., Patient Selection Criteria: Patients ≥60 years with OTA/AO 31B who underwent a cemented hip hemiarthroplasty from 10th December 2007 (database inception) to 15th November 2023 (search date) were reviewed.Outcome Measures and Comparisons: Comparisons were made between patients who underwent hip hemiarthroplasty with versus without pressurisation of the bone cement for outcomes 30-day post-operative mortality, revision for aseptic femoral component loosening, and revision for all-causes., Results: 406 procedures among 402 patients, and 722 procedures among 713 patients were performed with and without pressurisation of the bone cement respectively. Mean ages were 83.1 and 84.3 years (p=0.018), with 72.2% and 68.6% (p=0.205) females in the pressurised and non-pressurised cement patient groups respectively. There were no differences in 30-day post-operative mortality (7.2% versus 8.2%; HR 0.89, 95%CI 0.46-1.73, p=0.727). There were no differences in all-cause revision (HR 1.04, 95%CI 0.27-4.04, p=0.953). No revisions were performed for aseptic loosening. Survival at 10 years post-operatively was 15.3% (95%CI 11.46-19.64) and 12.6% (95%CI 7.67-18.82) among patients who underwent hemiarthroplasty with and without bone cement pressurisation respectively., Conclusions: There were no differences in 30-day post-operative mortality among patients who underwent hemiarthroplasty with, compared to, without bone cement pressurisation. Bone cement pressurisation did not confer any advantages for revision outcomes which may be attributed in part to patients' high mortality rate and low survival beyond 10 years post-operatively., Level of Evidence: Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Potential Conflicts of Interest and Funding Sources: The authors report no conflicts of interest. This study was not funded., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Acute fractures around the hip are prevalent injuries associated with potentially devastating outcomes. The growing utilization of arthroplasty for femoral neck fractures in the elderly is likely a result of improvements in reoperation rates and postoperative function. Compared to hemiarthroplasty, total hip arthroplasty is associated with a slight functional benefit that is unlikely noticeable for many patients, as well as minimal differences in complications and patient reported outcome measures. However, the evidence supporting cement use in femoral stem fixation is robust. Multiple high power randomized controlled trial-based studies indicate cement fixation brings more predictable outcomes and fewer reoperations. In the setting of acute acetabular fracture, total hip arthroplasty is a favorable approach for elderly patients and fracture patterns associated with increased risk of revision after open reduction and internal fixation. Variations in patient characteristics and fracture patterns demand careful consideration whenever selecting the optimal treatment. In fracture patient populations, comanagement is an important consideration when seeking to reduce complications and promote cost-effective quality care., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: To determine the accuracy of the intermalleolar method, an intraoperative fluoroscopic method for assessing tibial rotation in patients undergoing intramedullary nail fixation for tibial shaft fractures, by comparing it with the gold standard computed tomography (CT)., Design: Prospective cohort study., Setting: Academic Level 1 trauma center., Patient Selection Criteria: Consecutive patients, aged 18 years and older, with unilateral tibial shaft fractures who underwent intramedullary fixation from September 2021 to January 2023., Outcome Measures and Comparisons: Intraoperatively, tibial rotation measurements were obtained using the intermalleolar method on both the uninjured and injured limbs. Postoperatively, patients underwent bilateral low-dose lower extremity rotational CT scans. CT measurements were made by 4 blinded observers. Mean absolute rotational differences and standard errors were calculated to compare the injured and uninjured limbs. Subgroup analysis was performed assessing accuracy relating to injured versus uninjured limbs, body mass index, OTA/AO fracture pattern, tibial and fibular fracture location, and distal articular fracture extension requiring fixation., Results: Of the 20 tibia fractures, the mean patient age was 43.4 years. The intermalleolar method had a mean absolute rotational difference of 5.1 degrees (standard error 0.6, range 0-13.7) compared with CT. Sixty percent (24/40) of the measurements were within 5 degrees, 90% (36/40) of the measurements were within 10 degrees, and 100% (40/40) were within 15 degrees of the CT. No patients were revised for malrotation postoperatively., Conclusions: The intermalleolar method is accurate and consistently provides intraoperative tibial rotation measurements within 10 degrees of the mean CT measurement for adult patients undergoing intramedullary nail fixation for unilateral tibial shaft fractures. This method may be employed in the operating room to accurately quantify tibial rotation and assist with intraoperative rotational corrections., Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Fractures of the tibia and femur are common. Rotation of the limb can affect the outcome of the injury, both in the immediate term and the long term. Because plain radiographs are two dimensional, rotation is hard to assess radiographically. As a result, rotational malalignment is common. It is important to provide technical tips on the assessment of rotation preoperatively, intraoperatively, and postoperatively. The goal is to better assess rotation so that deformity can be minimized. This applies to fractures of the tibia and femur. Even after careful treatment, rotational deformities can occur. When they are symptomatic, correction should be considered. Techniques for correction of malrotation of both tibial and femoral fractures are presented.

Obesity is highly prevalent, and it is expected to grow considerably in the United States. The association between obesity and an increased risk of complications following total joint arthroplasty (TJA) is widely accepted. Many believe that patients with body mass index (BMI) >40 have complications rates that may outweigh the benefits of surgery and should consider delaying it. However, the current literature on obesity and outcomes following TJA is observational, very heterogeneous, and full of confounding variables. BMI in isolation has several flaws and recent literature suggests shifting from an exclusively BMI <40 cutoff to considering 5 to 10% preoperative weight loss. BMI cutoffs to TJA may also restrict access to care to our most vulnerable, marginalized populations. Moreover, only roughly 20% of patients instructed to lose weight for surgery are successful and the practice of demanding mandatory weight loss needs to be reconsidered until convincing evidence exists that supports risk reduction as a result of preoperative weight loss. Obese patients can benefit greatly from this life-changing procedure. When addressing the potential difficulties and by optimizing preoperative assessment and intraoperative management, the surgery can be conducted safely. A multidisciplinary patient-centered approach with patient engagement, shared decision-making, and informed consent is recommended., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Periprosthetic fractures (PPFx) are a severe complication of total hip and hemiarthroplasty. Surgical treatment is typically performed but can result in major morbidity. Nonoperative PPFx management may provide a successful treatment alternative in select patients., Methods: Vancouver B1 PPFx patients treated over a 10-year period were identified. Patient demographic data were retrospectively recorded. Injury and postoperative radiographs were reviewed. There were 48 patients who met the study criteria. Patients were divided into operative and nonoperative comparative cohorts. Outcome comparisons between the 2 cohorts included 1-year mortality, unplanned surgery within 24 months of injury, fracture union rate, and return to preinjury ambulation status., Results: There was no difference in 1-year mortality between the nonoperative and operative cohorts (17 versus 8%; P = .32). We found no significant difference in unplanned surgery between the nonoperative and operative groups (8.7 versus 12%; P = .71), fracture union (100 versus 96%, P = .34), or return to ambulation status (86 versus 91%; P = .86). Nonoperative fractures were minimally displaced and within the metaphyseal region of the proximal femur without stem subsidence. Nonoperative fractures with subsequent treatment failure had initial fracture extension closer to the tip of the stem compared to successfully treated nonoperative fractures (5.5 versus 10.2 centimeters; P = .02)., Conclusion: Select nonoperatively treated patients had infrequent need for unplanned surgery, high union rate, and return to their preinjury ambulation status. Nonoperative management is not appropriate for all Vancouver B1 PPFx, but those patients who have minimally displaced meta-diaphyseal fractures and partial remaining distal fixation can be successfully treated., (Published by Elsevier Inc.)

Introduction: Malicious cyberattacks are increasing in frequency and severity with healthcare institutions spending an average of over 10 million dollars to resolve the consequences of healthcare data breaches. This cost does not include the effect of a downtime event should a healthcare system electronic medical record (EMR) lose functionality. An Academic Level 1 trauma center suffered a cyberattack resulting in a total EMR downtime of 25 days. Orthopedic operative time was used as a surrogate for OR functionality during the event and a framework with specific examples is presented to promote rapid adaptation during downtime events., Methods: Operative time losses were identified by calculating a running average of weekday total in room operative time during a total downtime event secondary to a cyberattack. This data was compared to week-of-the-year matched data from the year prior and the year after the attack. A framework for creating adaptations to a total downtime event was created by repeatedly interviewing different provider groups and identifying how they adjusted care to the challenges faced., Results: Total weekday in room operative time during the attack decreased by 53.4% ± 12.2% and 53.2% ± 14.9% when comparing the matched period one year prior and one year after, respectively. Immediate challenges to patient care were identified by small groups of highly motivated individuals, with self-assigned agile teams formed. These teams sequenced system processes, identified failure points, and created real-time solutions. A frequently updated EMR backup mirror and hospital disaster insurance were crucial for mitigating the impact of the cyberattack., Conclusions: Cyberattacks are expensive and their downstream effects, including downtime events, can be crippling. Agile team formation, process sequencing, and understanding EMR backup times are tactics used to combat the challenges of a prolonged total downtime event., Level of Evidence: Level III retrospective cohort., (Copyright © 2023. Published by Elsevier Ltd.)

Noncemented press-fit femoral stems predominate in total hip arthroplasty for all age groups with generally excellent long-term survivorship. The 2021 American Joint Replacement Registry reports that 96% of all elective primary total hip arthroplasties used noncemented femoral implant fixation. 1 Today, there are many styles of press-fit stems, each with supposed benefits, based on a range of design philosophies. Design aspects to consider when selecting a stem are numerous, including stem geometry, stem length, collared or collarless, material properties, and surface structure. Although most stem designs demonstrate excellent results, the differences in stem designs are intimately linked to additional factors such as ease of use/implantation, percentage of surface osseointegration, overall bone removal versus bone stock preservation, subsequent femoral stress shielding, and consideration of complexity of later revision. A surgeon with a broad understanding and appreciation of femoral stem designs should be prepared to select between the multitude of options to best serve individual patients., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Total knee arthroplasty (TKA) is an important treatment option for knee osteoarthritis (OA) that improves self-reported pain and physical function, but objectively measured physical function typically remains reduced for years after surgery due, in part, to precipitous reductions in lower extremity neuromuscular function early after surgery. The present study examined intrinsic skeletal muscle adaptations during the first 5 weeks post-TKA to identify skeletal muscle attributes that may contribute to functional disability. Patients with advanced stage knee OA were evaluated prior to TKA and 5 weeks after surgery. Biopsies of the vastus lateralis were performed to assess muscle fiber size, contractility, and mitochondrial content, along with assessments of whole muscle size and function. TKA was accompanied by marked reductions in whole muscle size and strength. At the fiber (i.e., cellular) level, TKA caused profound muscle atrophy that was approximately twofold higher than that observed at the whole muscle level. TKA markedly reduced muscle fiber force production, contractile velocity, and power production, with force deficits persisting in myosin heavy chain (MHC) II fibers after expression relative to fiber size. Molecular level assessments suggest reduced strongly bound myosin-actin cross bridges and myofilament lattice stiffness as a mechanism underlying reduced force per unit fiber size. Finally, marked reductions in mitochondrial content were apparent and more prominent in the subsarcolemmal compartment. Our study represents the most comprehensive evaluation of skeletal muscle cellular adaptations to TKA and uncovers novel effects of TKA on muscle fiber size and intrinsic contractility early after surgery that may contribute to functional disability. NEW & NOTEWORTHY We report the first evaluation of the effects of total knee arthroplasty (TKA) on skeletal muscle at the cellular and subcellular levels. We found marked effects of TKA to cause skeletal muscle fiber atrophy and contractile dysfunction in older adults, as well as molecular mechanisms underlying impaired contractility. Our results reveal profound effects of TKA on muscle fiber size and intrinsic contractility early after surgery that may contribute to functional disability.

Objective: To investigate the degree of error due to parallax during intraoperative rotational imaging involving the distal femur., Methods: Twelve, fresh-frozen, lower-extremity cadaveric specimens were studied. The limbs were positioned supine and rotated until the posterior femoral condyles were superimposed using a C-arm. The C-arm was then repositioned to place the femoral condyles at the anterior and posterior margins of the image intensifier. The rotation necessary to resuperimpose the femoral condyles due to parallax was recorded. A second C-arm was then used from the contralateral side to simulate the rotational imaging technique to determine the magnitude and directionality of combined parallax., Results: All 12 specimens demonstrated parallax, resulting in rotational discrepancies. Compared with central field of view alignment, the mean rotational discrepancy was 5.6 and 5.5 degrees for anterior and posterior positions, respectively. Contralateral imaging resulted in an additive effect with rotational differences of 9.0 and 12.6 degrees for bilateral anterior and posterior positions, respectively., Conclusions: Parallax causes rotational discrepancies with fluoroscopic imaging of the distal femur when the posterior femoral condyles are off-center in the imaging field of view. If femoral condyles are not centered when obtaining intraoperative rotational imaging of the uninjured and injured femurs, parallax can result in potentially clinically significant rotational deformity even if the femurs seem perfectly matched at the conclusion of surgery. We recommend perfectly centering of the posterior femoral condyles in the imaging field of view when obtaining lateral images of the distal femur to prevent this potentially overlooked contribution to malrotation., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Evaluate how total knee arthroplasty (TKA) implant design, femoral component size, and preoperative knee range of motion affect retrograde femoral nailing., Methods: Cadaveric specimens were prepared for TKA with a single radius (SR) or medial pivot (MP) design and tested with cruciate retaining (CR), cruciate substituting (CS), and posterior stabilizing (PS) 9-mm liners. Knee extension identified the minimum flexion required to pass an opening reamer without impinging on TKA components. The angle between the reamer path and the femoral shaft was calculated from lateral fluoroscopic images., Results: In SR TKA, the average flexion required was 70, 71, and 82 degrees for CR, CS, and PS, respectively. The required flexion in PS was significantly greater (P = 0.03). In MP TKA, the average flexion required was 74, 84, and 123 degrees for CR, CS, and PS, respectively. The required flexion was significantly greater in CS and PS designs (P < 0.0001). Femoral component size did not affect the minimum flexion required. The entry reamer resulted in 9.2 (SR) and 12.5 (MP) degrees of apex anterior deviation., Conclusions: When performing retrograde nailing through either of these TKA designs with a 12-mm opening reamer, at least 70 degrees of knee flexion is required to avoid damage to the polyethylene liner or femoral component. PS implants require significantly more flexion with both TKA designs. Femoral component size did not affect the flexion requirement. Approximately a 10-degree deviation exists between the reamer path and femoral shaft., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the accuracy and reliability of a novel fluoroscopic technique for assessing tibial rotation and compare it with a previously described fluoroscopic method., Methods: A multiplanar circular ring external fixator was secured to the tibial diaphysis of 5 cadaveric lower extremity specimens. Using deformity correction software, the frame and tibia were programed to randomly rotate 5, 10, 15, 20, 25, and 30 degrees of internal and external rotation. After each rotation, 2 blinded, independent observers measured the degree of tibial rotation using 2 different fluoroscopic methods: the previously described "mortise" method and the novel "intermalleolar" method. A total of 65 measurements were made by each observer. Accuracy and interobserver reliability were calculated., Results: Both intermalleolar and mortise methods had a mean absolute rotational difference from the true torsion of 3 degrees (standard error 1; range, 0-10 degrees intermalleolar vs. 0-18 degrees mortise). We found that 98.5% (128/130) of measurements using the intermalleolar method were less than 10 degrees from the true rotation compared with 93.8% (122/130) using the mortise method. Both the intermalleolar and the mortise methods had excellent interobserver reliability (intraclass correlation coefficient 0.99 and 0.96, respectively)., Conclusion: Measuring tibial rotation fluoroscopically using the intermalleolar method is both accurate and reliable. Compared with the previously described mortise method, it has similar accuracy and provides a value that approximates the true tibial rotation. Also, it can be used reliably and effectively intraoperatively to identify tibial malrotation and assist in intraoperative rotational corrections., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Direct anterior approach (DAA) total hip arthroplasty (THA) in a supine position provides a unique opportunity to assess leg length discrepancy (LLD) intra-operatively with fluoroscopy. Reported fluoroscopic techniques are useful but are generally complicated or costly. Despite the use of multiple techniques for leg length assessment, LLD continues to be a major post-operative source of patient dissatisfaction further emphasizing the importance of near-anatomic restoration. The utility of an alternative direct measurement of LLD on an intra-operative fluoroscopic pelvic image during DAA THA has not been reported., Aim: To determine the reliability of a novel simple intra-operative measurement of LLD using a parallel line technique on a single fluoroscopic digital image of the pelvis., Methods: One hundred and seventy-one patients who underwent DAA THA were included for analysis. Intra-operative fluoroscopic and post-operative anterior-posterior radiographs were imported to TraumaCad and calibrated for LLD measurement. LLD was measured on each image using the right-left hip differences in lesser trochanter to pelvic reference line distances. Pelvic reference points included the teardrops and ischia. Fluoroscopic LLD was compared to the gold-standard measurement of LLD measured on a post-operative radiograph., Results: Mean absolute difference in teardrop referenced LLD between fluoroscopic and post-operative radiographs was 2.17 mm and based on the ischia mean absolute difference was 2.63 mm. Linear regression of fluoroscopic and post-operative radiograph LLD based on teardrop and ischia LLD found r 2 values of 0.57 and 0.84, respectively. Mean absolute difference between fluoroscopic and post-operative x-ray LLD was within 5 mm in 95% of cases regardless of pelvic reference., Conclusion: This study demonstrates that a single fluoroscopic view obtained during DAA THA for leg length assessment is clinically useful., Competing Interests: Conflict-of-interest statement: We have no financial relationships to disclose., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Introduction: Although surgical fixation is routinely recommended for geriatric hip fractures, nonoperative treatment may be an option for certain stable fracture patterns. Occult hip fractures are nondisplaced fractures not evident on radiographs, but display intraosseous edema on MRI. Our aim is to report the rate of nonoperative treatment failure in patients with occult geriatric hip fractures., Methods: All nonoperatively treated femoral neck or intertrochanteric femur fractures (AO/OTA 31A and 31B) from 2003 to 2018 were identified. Patients older than 65 years with negative radiographs but a hip fracture evident on MRI were included. Patients who died prior to fracture displacement or union were excluded. Charts and imaging were reviewed for demographic data, fracture type, clinical course, displacement, and whether corrective surgery was performed., Results: Of 15 final study patients, there were 6 femoral neck and 9 intertrochanteric fractures. Two fractures displaced, both requiring surgery (2/15; 13.3%). Both displacements occurred in the femoral neck group (2/6; 33%) compared to none in the intertrochanteric cohort (0/9; 0%). This trend did not reach statistical significance (p = 0.14)., Conclusion: Thirty-three percent (2/6, 33%) of femoral neck fractures displaced and required surgery. The remainder of the cohort (13/15, 87%) healed without complication, including all of the intertrochanteric fractures (9/9, 100%). Although this difference did not reach statistical significance, the results may better inform treatment discussions for geriatric patients with occult hip fractures diagnosed by MRI., Level of Evidence: Level III.

Purpose: This study aimed to determine if standardized updates at specific perioperative events affect anxiety and satisfaction of the family members and if the length of surgical procedure affects the satisfaction with updates., Methods: This study was a randomized control trial. In the control group, surgeons communicated with the family only once near the completion of the procedure. In the intervention group, families received electronic updates at 3 significant perioperative events during the procedure. A postoperative survey rating family member satisfaction and anxiety levels, using a Likert scale of 0-5, was administered., Results: Mean level of overall satisfaction did not differ between groups (intervention: 4.68 ± 0.69 [95% CI: 4.50, 4.87]; control: 4.61 ± 0.78 [95% CI: 4.40, 4.82]; P=0.69). Mean anxiety levels were lower in the intervention group (2.48 ± 1.43 [2.10, 2.86]) than in the control group (3.12 ± 1.32 [2.77, 3.47]; P=0.01). Mean satisfaction with perioperative updates was higher in the intervention (4.48 ± 0.83 [4.26, 4.70]) versus control group (3.16 ± 1.89 [2.67, 3.65]; P=0.0001). For all subjects, there was positive correlation between procedure time and anxiety (Spearman's rho: 0.34; P=0.0002) and negative correlation between procedure time and overall satisfaction (Spearman's rho: -0.23; P=0.01)., Conclusions: Anxiety and satisfaction with perioperative updates were significantly improved by additional perioperative updates. These findings indicate that updating families during significant standardized strategic perioperative events can reduce the anxiety of loved ones and are preferred by most families., Competing Interests: Conflicts of Interest None., (© 2021 Aurora Health Care, Inc.)

Background: Knee osteoarthritis nonoperative management options remain limited. Our aim is to define the current American Association of Hip and Knee Surgeons (AAHKS) members' practices and perceptions in terms of the frequency, formulation, use of concomitant aspiration, maximum lifetime number of injections, efficacy, interval between injection and surgery and complication rates., Methods: A 22-question survey based on Likert scale response anchors was approved and distributed by the AAHKS Research Committee to its membership by email during the Spring 2019 meeting. Data were managed with REDCap software., Results: Membership response totaled 537 of 2365 (22.7%) members. Highlights include every respondent using intra-articular corticosteroid injections (ICIs) in their practice, and most use a three-month minimum interval, although the preferred interval is longer. Near consensus was found waiting three months before surgery. There was a great variability in the number of injections allowed, and injections before surgery were very common. Nearly all responders use a local anesthetic mixture with the cortisone injection, but there was great variation in corticosteroid type: methylprednisolone (42%), triamcinolone (41%), betamethasone (13.3%), and dexamethasone (3.7%)., Conclusion: The results of our survey indicate the majority of the AAHKS members who completed the survey use ICIs routinely for treatment of knee osteoarthritis. There was near consensus in ICIs, which is effective with decreasing efficacy over serial injections, and an absolute minimum interval between injections was believed by most to be three months with no clearly defined lifetime limit and strong consensus for a three-month preoperative interval. The formulation of steroid, local anesthetic, and skin preparation technique varied greatly., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To determine if cancellous screw (CS) and sliding hip screw (SHS) technical factors during low-energy femoral neck fracture fixation affects a 24-month revision surgery rate and health-related quality of life (HRQL)., Design: Prospective randomized controlled study., Setting: International, multicenter., Patients: Eight hundred ninety-eight femoral neck fracture patients age 50 years and older., Intervention: Patients were randomized to fracture stabilization with either CSs or a SHS device as part of the Fixation Using Alternative Implants for the Treatment of Hip Fractures (FAITH) trial. CS technical factors analyzed included screw diameter, short versus long screw threads, screw number and formation, screw orientation, and washer use. SHS technical factors studied were side plate length, supplemental screw use, lag screw position, and tip-apex distance., Main Outcome Measurements: Revision surgeries within 24 months to promote fracture healing, relieve pain, treat infection, or improve function. In addition, HRQL measures were collected, including the SF-12 Physical Component Score and Western Ontario and McMaster Universities Osteoarthritis Index., Results: The 3-screw inverted triangle pattern had a significantly lower revision surgery rate than a 3-screw triangle formation (P = 0.004). No other CS or SHS technical factors were predictive of revision surgery or affected a patient's HRQL (P > 0.05)., Conclusions: A 3-screw inverted triangle pattern was superior to a 3-screw triangle formation. However, injury and patient factors such as fracture displacement, age, smoking status and sex play a more significant role in clinical outcomes for low-energy femoral neck fracture treatment., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In March 2020, elective total hip and knee arthroplasty (THA and TKA) were suspended across the United States in response to the COVID-19 pandemic. We had previously published the results of a survey to the affected patients from 6 institutions. We now present the results of a larger distribution of this survey, through May and June 2020, to electively scheduled patients representing different regions of the United States., Methods: Fifteen centers identified through the American Association of Hip and Knee Surgeons Research Committee participated in a survey study of THA and TKA patients. Patients scheduled for primary elective THA or TKA but canceled due to the COVID-19 elective surgery stoppage (3/2020-5/2020) were included in the study. Descriptive statistics along with subgroup analysis with Wilcoxon rank were performed., Results: In total, surveys were distributed to 2135 patients and completed by 848 patients (40%) from 15 institutions. Most patients (728/848, 86%) had their surgery postponed or canceled by the surgeon or hospital. Unknown length of surgical delay remained the highest source of anxiety among survey participants. Male patients were more likely to be willing to proceed with surgery in spite of COVID-19. There were minimal regional differences in responses. Only 61 patients (7%) stated they will continue to delay surgery for fear of contracting COVID-19 while in the hospital., Conclusion: Similar to the previous study, the most anxiety-provoking thought was the uncertainty, over if and when the canceled joint replacement surgery could be rescheduled. Patients suffering from the daily pain of hip and knee arthritis who have been scheduled for elective arthroplasty remain eager to have their operation as soon as elective surgery is allowed to resume., (© 2021 Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons.)

Background: In 2013, the American Academy of Orthopaedic Surgeons (AAOS) published an evidence-based clinical practice guideline (CPG) on conservative treatment options for patients with knee osteoarthritis (OA). The purpose of this study is to evaluate the effectiveness of a poster outlining the AAOS knee OA CPG on patient comprehension and satisfaction in the clinic., Methods: This is a prospective 2-armed randomized controlled trial. Patients were eligible if they were of age 40-85 years, had degenerative knee OA, and did not consent for surgery. Patients were randomized to nonposter (standard care) and poster rooms. Knee OA treatment options were described to the patient verbally and posters were used as a teaching tool when present. The main outcomes were comprehension and satisfaction scores on a survey., Results: Of the 105 patients enrolled, 51 (48.6%) were randomized to usual care (control) and 54 (51.4%) to the intervention (poster). Poster patients outperformed control patients with an average of 55.3% ± 16.7% (mean ± SD) compared to 39.5% ± 13.3% correct answers (P < .001). And 66.7% of poster patients and 29.4% of control patients achieved an adequately informed status of >50% correct answers (P < .001; 50.5% overall). With a maximum possible score of 10, visit satisfaction scores were 9.4 ± 1.0 in poster patients and 9.2 ± 1.7 in control patients (P = .50)., Conclusion: Patients educated using an AAOS knee CPG poster showed significant improvements in knowledge and were more likely to achieve an adequately informed status. No difference existed in visit satisfaction. A poster offers a low-cost, effective educational tool., Level of Evidence: Level 1., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: HEALTH was a randomized controlled trial comparing total hip arthroplasty with hemiarthroplasty in low-energy displaced femoral neck fracture patients aged ≥50 years with unplanned revision surgery within 24 months of the initial procedure being the primary outcome. No significant short-term differences between treatment arms were observed. The primary objective of this secondary HEALTH trial analysis was to determine if any patient and surgical factors were associated with increased risk of revision surgery within 24 months after hip fracture., Methods: We analyzed 9 potential factors chosen a priori that could be associated with revision surgery. The factors included age, body mass index, major comorbidities, independent ambulation, type of surgical approach, length of operation, use of femoral cement, femoral head size, and degree of femoral stem offset. Our statistical analysis was a multivariable Cox regression using reoperation within 24 months of index surgery as the dependent variable., Results: Of the 1441 patients included in this analysis, 8.1% (117/1441) experienced reoperation within 24 months. None of the studied factors were found to be predictors of revision surgery (P > 0.05)., Conclusion: Both total and partial hip replacements are successful procedures in low-energy displaced femoral neck fracture patients. We were unable to identify any patient or surgeon-controlled factors that significantly increased the need for revision surgery in our elderly and predominately female patient population. One should not generalize our findings to an active physiologically younger femoral neck fracture population., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: Oscillating saws are commonly used for bone preparation in total knee arthroplasty but can cause injury to the posterior neurovascular bundle during tibial resection. Tip-oscillating saw blades are a recent innovation that could improve saw control due to decreased excursion; however, the tactile feedback to the surgeon is different., Methods: To compare traditional hub and new tip-oscillating saw blades, 16 participants of varying levels of experience were video-recorded during composite tibial bone model resections to measure posterior saw blade plunge. Subjective perceptions of saw control and preference were also surveyed., Results: Saw blade design and level of surgical experience did not produce a significant difference in posterior saw blade plunge (P > .05). Independent of saw blade design, subjects with no previous saw experience had significantly decreased posterior tibial plunge over subsequent resections. Tip-oscillating saw blades were perceived to be easier to use and control by less experienced participants (P = .0163)., Conclusion: Tip-oscillating saw blades do not alter the risk of posterior tibial saw plunge compared with traditional saw blades., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Over the past decade, 2 randomized controlled trials were performed to evaluate 2 surgical strategies (internal fixation and arthroplasty) for the treatment of low-energy femoral neck fractures in patients aged ≥50 years. We evaluated whether patient populations in both the FAITH and HEALTH trials had different baseline characteristics and compared the displaced femoral neck fracture cohort from the FAITH trial to HEALTH trial patients., Methods: Patient demographics, medical comorbidities, and fracture characteristics from both trials were compared. FAITH trial patients with displaced fractures were then compared with HEALTH patients. T-tests and χ tests were performed to compare differences for sex, age, osteoporosis status, and ASA class., Results: The mean age of the 1079 FAITH trial patients was 72 versus 79 years for the 1441 HEALTH trial patients. HEALTH patients were older, mostly White, used more medication, and had more comorbidities than FAITH patients. Of the 1079 FAITH trial patients, 32% (346/1079) had displaced fractures. Their mean age was significantly lower than that of HEALTH patients (66 vs. 79 years; P < 0.001). HEALTH trial patients were significantly more likely to be female, have ASA classification Class III/IV/V, and carry a diagnosis of osteoporosis, as compared with the subgroup of FAITH patients with displaced femoral neck fractures (P < 0.001)., Conclusion: This study demonstrates significant differences between patients enrolled in the 2 trials. Although both studies focused on femoral neck fractures with similar enrollment criteria, patient populations differed. This sheds light on a noteworthy limitation of discordant patient enrollment into randomized trials, despite similar eligibility criteria., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Notable advances in hip arthroplasty implants and techniques over the past 60 years have yielded excellent survivorship of fully cemented, hybrid, and reverse hybrid total hip replacements as demonstrated in joint registries worldwide. Major advances in noncemented implants have reduced the use of cement, particularly in North America. Noncemented implants predominate today based on procedural efficiency, concern related to thromboembolic risk, and a historic belief that cement was the primary cause of osteolysis and implant loosening. With the decline of cemented techniques, press-fit fixation has become common even in osteoporotic elderly patients. Unfortunately, there is a troubling rise in intraoperative, as well as early and late postoperative periprosthetic fractures associated with the use of noncemented implants. Despite the success of noncemented fixation, an understanding of modern cement techniques and cemented implant designs is useful to mitigate the risk of periprosthetic fractures. Cemented acetabular components can be considered in elderly patients with osteoporotic or pathologic bone. Cemented stems should be considered with abnormal proximal femoral morphology, conversion of failed hip fixation, inflammatory arthritis, patient age over 75 (especially women), osteoporotic bone (Dorr C), and in the treatment of femoral neck fractures.

Background: Perioperative glucocorticoids are routinely administered to patients undergoing total joint arthroplasty (TJA) to decrease postoperative pain and nausea. However, there is concern regarding the effects of glucocorticoids on perioperative glucose control in diabetes. The goal of this study is to determine if administration of preoperative dexamethasone to diabetic patients is significantly associated with hyperglycemia and increased insulin requirements in the immediate postoperative period after TJA and to identify risk factors for postoperative hyperglycemia immediately after TJA., Methods: A retrospective review of type 2 diabetic patients undergoing TJA from 2010 to 2015 (n = 285) was undertaken to evaluate the effect of dexamethasone on postoperative glucose control. Preoperative baseline characteristics were compared between patients who did and did not receive 8 mg of intravenous dexamethasone preoperatively. Postoperative glucose and insulin requirements were evaluated with respect to dexamethasone dosing. Statistical analysis was performed using logistic regression models., Results: Dexamethasone administration did not correlate with the maximum postoperative blood glucose (P = .78). There was a significantly higher initial postoperative blood glucose after intravenous dexamethasone administration (P < .01). Dexamethasone administration was associated with increased aspart insulin requirements on postoperative day 0 (P = .04). However, preoperative hemoglobin A1c was most strongly associated with postoperative glucose control., Conclusion: Preoperative dexamethasone administration to diabetic patients was associated with an initial increase in blood glucose and increased insulin requirement on postoperative day 0. Yet the observed effect on glucose control in diabetic patients may not outweigh the known clinical benefits of perioperative glucocorticoids., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The influence of total hip arthroplasty surgical approach on postoperative recovery is not well understood and often debated. This study compares anterior and posterior approach (PA) gait and patient-reported Hip Osteoarthritis Outcome scores (HOOS) in the early phases of recovery., Methods: A prospective study evaluated 20 control subjects, 35 direct anterior approach (DAA), and 34 PA total hip arthroplasty patients. Subjects were assessed preoperatively and at 1 and 4 months postoperatively with HOOS and smartphone gait assessments of gait speed, step length, cadence, step symmetry, and horizontal and vertical center of mass displacements., Results: The DAA and PA groups were not different in baseline HOOS or gait characteristics except for less horizontal center of mass displacement in the DAA group. At 1 month postoperatively, the DAA group had significantly faster gait speed at self-selected (P = .02) and fastest possible gait (P = .01) and longer step length at self-selected (P = .047) and fastest gait (P = .003) compared to the PA. At 4 months, there were no differences in DAA and PA gait measures. At 1 month postoperatively there were no significant differences in HOOS, but after 4 months HOOS were significantly higher in the DAA group., Conclusion: There were minimal differences between the two approaches in the recovery of gait mechanics with some gait parameters particularly gait speed and step length recovery favoring the DAA at 1 month postsurgery in this nonrandomized study., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To report the mortality data and life expectancy of geriatric hip fracture patients who underwent nonoperative management and compare that with a matched operative cohort., Design: Retrospective cohort study., Setting: Level 1 trauma center., Patients: Geriatric (65 years of age and older) femoral neck or intertrochanteric fracture (OTA/AO 31A and 31B) patients., Intervention: Operative treatment with either arthroplasty, cannulated screws, sliding hip screw device, or cephalomedullary nail compared with nonoperative cohort., Main Outcome Measurements: In-hospital, 30-day, and 1-year mortality., Results: Two hundred thirty-one patients, comprising 154 operative and 77 nonoperative patients, were compared. There were no significant differences among age, sex, fracture location, Charlson Comorbidity Index, preinjury living location, dementia, and history of cardiac arrhythmia between the 2 cohorts. Nonoperatively managed patients were found to have a significantly higher percent in-hospital (28.6 vs. 3.9; P < 0.0001), 30-day (63.6 vs. 11.0; <0.0001), and 1-year (84.4 vs. 36.4; P < 0.0001) mortality. The mean life expectancy after a hip fracture for the nonoperative cohort was significantly shorter than the operative group (221 vs. 1024 days; P < 0.0001)., Conclusions: Nonoperatively treated hip fracture patients had an 84.4% 1-year mortality that was significantly higher than a matched operative cohort. Our results demonstrate the bleak overall prognosis for nonoperatively treated geriatric hip fractures as well as the associated reduction in mortality with surgical treatment. Our findings offer helpful information by providing updated mortality data when discussing nonoperative hip fracture management with patients and their family., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

There is a significant global burden of disease associated with the management of hip fractures. Despite numerous studies that are focused on the treatment of patients with proximal femur fractures, the management of these injuries remains controversial. Clinicians should become familiar with the current evidence regarding the management of these common injuries and understand the key issues and controversies because they will have important implications given the large-scale effect of hip fractures internationally.

Objectives: The diagnosis and treatment of syndesmotic ankle fractures is controversial. This systematic review was performed to clarify the current understanding addressing several clinical questions that arise in the treatment of such injuries., Data Sources: The English language literature was searched using PubMed, EMBASE, and Web of Science. The search terms were "syndesmosis" or "syndesmotic" in combination with the terms "ankle fracture" or "fracture." The included dates were between 1967 and July 2015., Study Selection: Inclusion criteria were number of patients >20, patient age ≥18 years, follow-up ≥1 year, ankle fracture classification was reported, criteria for surgery was reported, technique of surgery was reported, and a validated outcome measure was used. Studies limited to biomechanical or imaging investigations were excluded., Data Extraction: Information was abstracted using a standardized template, which encompassed the inclusion criteria together with the study type, postoperative regimen, and complications. Study quality was evaluated using the modified CONSORT statement and Coleman criteria. Study bias was assessed, and methodological quality was rated. Any difference in ratings was resolved by consensus., Data Synthesis: None., Conclusions: The overall quality of the studies was poor. The number or placement of syndesmotic screws or the breakage of trans-syndesmotic screws postoperatively had no adverse effect on outcomes (both with moderate strength of evidence). The use of alternative fixation devices (bioabsorbable and endobutton) had poor strength of evidence, as did the opinion that nondisplaced, unstable by stress test, syndesmotic injuries required fixation. There are insufficient data that link subtle rotational syndesmotic malreduction to clinical outcomes., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Periprosthetic femoral shaft fractures are a significant complication after total hip arthroplasty (THA). Plate osteosynthesis has been the mainstay of treatment around well-fixed stems. Nonunions are a rare and challenging complication of this fixation method. We report the outcomes of a novel orthogonal plating surgical technique for Vancouver B1 and C-type periprosthetic fractures that previously failed open reduction internal fixation (ORIF)., Methods: A retrospective review identified all patients with Vancouver B1/C THA periprosthetic femoral nonunions from 2010 to 2015. Exclusion criteria included open fractures and periprosthetic infections. The technique utilised a mechanobiologic strategy of atraumatic exposure, resection of necrotic tissue, bone grafting with adjuvant bone morphogenetic protein (BMP) and revision open reduction internal fixation with orthogonal plate osteosynthesis., Results: 6 Vancouver B1/C periprosthetic femoral nonunions were treated. 5 patients were female with an average age of 80.3 years (range 72-91 years). The fractures occurred at a mean of 5.8 years (range 1-10 years) from their initial arthroplasty procedure. No patients underwent further revision surgery; there were no perioperative complications. All patients had a minimum of 11 months follow-up (mean 18.6, range 11-36 months). All fractures achieved osseous union, defined as solid bridging callus over at least 2 cortices and pain free, independent ambulation, at an average of 24.4 weeks (range 6.1-39.7 weeks)., Conclusions: This is the 1st series describing orthogonal locked compression plating using modern implants for periprosthetic femoral nonunions. This technique should be considered in periprosthetic femur fracture nonunions around a well-fixed stem.

Background: Following total knee and hip arthroplasty, patient progress can be assessed with patient-reported outcome measures (PROMs) and performance-based outcome measures (PBOMs). The American Joint Replacement Registry 2016 guide recommends collecting several measures, including Patient Reported Outcome Measure Information System Global, Knee Injury and Osteoarthritis Outcome Score Jr, and Hip Injury and Osteoarthritis Outcome Score Jr. This study aimed to assess the current and anticipated use of PROMs and PBOMs by New England physical therapists., Methods: An online survey was conducted in July and August of 2015 asking physical therapists in New England to rate their current and anticipated future use of PROMs and PBOMs in terms of clinical decision making associated with the treatment and care of patients after total hip and knee replacement., Results: There were 122 responses. The most often used and recommended PROMS were the Numeric Pain Rating Scale (99.2% and 97.5%, respectively) and Lower Extremity Function Scale (76.2% and 77.0%). There was significant variability in the use of different PBOMs, but the most often used and recommended were the Timed Up and Go (93.4% and 85.2%) and the Single Leg Balance Test (90.2% and 87.7%)., Conclusions: This study suggests that orthopaedic surgeons and physical therapists use different PROMs and PBOMs for postoperative assessment of total joint patients and highlights the need for more collaboration and consistency between these disciplines.

Lateral talar process fragment excision may be followed by hindfoot instability and altered biomechanics. There is controversy regarding the ideal fragment size for internal fixation versus excision and a concern that excision of a large fragment may lead to significant instability. The aim of this study was to assess the effect of a simulated large lateral talar process excision on ankle and subtalar joint stability.A custom-made seesaw rig was designed to apply inversion/eversion stress loading on 7 fresh-frozen human cadaveric lower legs and investigate them in pre-excision, 5 cm and 10 cm lateral talar process fragment excision states. Anteroposterior radiographs were taken to assess ankle and subtalar joint tilt and calculate angular change from neutral hindfoot alignment to 10-kg forced inversion/eversion. Ankle joint pressures and contact areas were measured under 30-kg axial load in neutral hindfoot alignment.In comparison to the pre-excision state, no significantly different mediolateral angular change was observed in the subtalar joint after 5 and 10 cm lateral talar process fragment excision in inversion and eversion. With respect to the ankle joint, 10-cm fragment excision produced significantly bigger inversion tibiotalar tilt compared with the pre-excision state, P = .04. No significant change of the ankle joint pressure and contact area was detected after 5 and 10-cm excision in comparison with the pre-excison state.An excision of up to 10 cm of the lateral talar process does not cause a significant instability at the level of the subtalar joint but might be a destabilizing factor at the ankle joint under inversion stress. The latter could be related to extensive soft tissue dissection required for resection.

Objectives: The benefits of cement augmentation with fixation of osteoporotic pertrochanteric fractures have been previously demonstrated. The objective of this study was 3-fold: (1) To quantify the intraosseous pressure produced during cement augmentation of the perforated proximal femoral nail antirotation (PFNA) blades; (2) To assess whether the pressure generated is influenced by the injection rate; and (3) To assess the amount of force applied during the injection., Methods: Six pairs of human cadaveric femurs were used in the study. A basicervical osteotomy was performed, and the heads were instrumented with the PFNA blade. Each pair was randomly assigned into 1 of 2 groups: slow versus rapid injection with polymethylmethacrylate (PMMA) cement. In the slow group, the augmentation was performed using 6 consecutive 1 mL injections, each over 10 seconds. In the rapid group, each 1 mL injection was performed over 5 seconds. For intraosseous pressure measurements, transmitters were inserted to a depth of 5 mm at both the superior and inferior apices of the head. The reaction forces on the syringe were measured as well., Results: There were no significant differences between the slow and rapid injection rates with respect to the peak pressures measured at the 6 time points immediately after cement injection. In both groups, elevations in pressure were transient and returned to baseline values within 30 seconds. The highest pressure recorded in the slow group was 37.3 and 30.7 mm Hg in the rapid group. The force required after each sequential injection increased in both groups; however, significantly higher forces were required to inject cement over 5 than 10 seconds (P = 0.036)., Conclusions: This in vitro model is the first one to demonstrate that femoral head cement augmentation is associated with a small transient increase in intraosseous pressure with sequential fast and slow 1 mL injections of up to 6 mL PMMA. We conclude that cement augmentation of the perforated PFNA blade carries a low risk of pressure-induced avascular necrosis.

Background: The aim of this study was to compare the effect of supine versus lateral position on clinical signs of fat embolism during orthopedic trauma surgery. Dogs served as the current study model, which could be extended and/or serve as a basis for future in vivo studies on humans. It was hypothesized that there would be an effect of position on clinical signs of fat embolism syndrome in a dog model., Materials and Methods: 12 dogs were assigned to supine (n = 6) and lateral (n = 6) position groups. Airway pressures, heart rate, blood pressure, cardiac output, pulmonary artery pressure, pulmonary artery wedge pressure, right atrial pressure, arterial and venous blood gases, white blood count, platelet count and neutrophil count were obtained. Dogs were then subjected to pulmonary contusion in three areas of one lung. Fat embolism was generated by reaming one femur and tibia, followed by pressurization of the canal., Results: No difference was found in any parameters measured between supine and lateral positions at any time (0.126 < P < 0.856)., Conclusions: The position of trauma patients undergoing reamed intramedullary nailing did not alter the presentation of the features of the lung secondary to fat embolism.

Background: Academic partnerships between high- and low/middle-income countries can improve the quality of surgical education and health care delivery in each setting. We report the perceived needs related to collaborative surgical education in a resource-limited setting., Methods: We used qualitative methods to elicit the opinions of surgical faculty members and surgical residents and quantitative methods to outline surgical procedure type and volume., Results: Ethiopian faculty members identified the management of trauma and emergency surgical care as a priority. They identified supervision in the operating room (OR), topic-specific lectures and supervising resident assessments in the clinic as appropriate roles for partners. Residents were in agreement with faculty members, highlighting a desire for supervision in the OR and topic-specific lectures., Conclusion: We present specific experiences and needs of a surgical teaching unit in a low-income country, paving the way to form a meaningful and responsive relationship between 2 surgical departments in 2 universities.

Background: The objective of this study was to assess the role of pulmonary fat embolism caused by intramedullary pressurization of the femoral canal in the development of acute lung injury in the setting of acute hemorrhagic shock and resuscitation., Methods: Thirty New Zealand White rabbits were randomly assigned to one of four groups: (1) nine animals in which hemorrhagic shock was induced by carotid bleeding, resuscitation was performed, and the femoral canal was reamed and pressurized with bone cement to induce fat embolism (hemorrhagic shock and resuscitation/fat embolism [HR/FE] group); (2) six animals in which shock was induced by carotid bleeding, resuscitation was performed, and a sham knee incision was made and closed without drilling, reaming, or pressurization (hemorrhagic shock and resuscitation [HR] group); (3) eight animals in which no hemorrhage or shock was induced but the femoral canal was reamed and pressurized with bone cement to induce fat embolism (fat embolism [FE] group); and (4) seven animals that had a three-hour ventilation period followed by a sham knee incision (control group). The animals were ventilated for four hours following closure. Flow cytometry with use of antibodies against CD45 and CD11b was performed to test neutrophil activation in whole blood. Histological examination of lung specimens was also performed. Plasma and bronchoalveolar lavage fluid were analyzed for monocyte chemotactic peptide-1 and interleukin-8 levels with use of the ELISA (enzyme-linked immunosorbent assay) method., Results: Three animals in the HR/FE group died immediately after canal pressurization and were excluded. CD11b mean channel fluorescence was significantly elevated, as compared with baseline, only in the HR/FE group at two hours (p = 0.025) and four hours (p = 0.024) after knee closure. Histological analysis showed that only the HR/FE (p < 0.001) and HR (p = 0.010) groups had significantly greater infiltration of alveoli by polymorphonuclear leukocytes as compared with that in the controls. No significant differences in plasma cytokine levels were found between the groups. Only the HR/FE group had significantly higher interleukin-8 (p = 0.020) and monocyte chemotactic peptide-1 (p = 0.004) levels in the bronchoalveolar lavage fluid as compared with those in the controls., Conclusions: Fat embolism from canal pressurization alone did not activate a pulmonary inflammatory response. The combination of hemorrhagic shock, resuscitation, and fat embolism elicited neutrophil activation, infiltration of alveoli by polymorphonuclear leukocytes, and inflammatory cytokine expression in bronchoalveolar lavage fluid.